The role of footwear and foot characteristics in reducing falls in older people The WritePass Journal

The role of footwear and foot characteristics in reducing falls in older people Introduction The role of footwear and foot characteristics in reducing falls in older people NICE (2011) NICE-recommended risk assessments help prevent falls in elderly nice.org.uk/newsroom/news/NICERecommendedRiskAssessmentsHelpPreventFallsInElderly.jsp Accessed 28/2/13 Sherrington Catherine; Menz, Hylton B.; (2002) An evaluation of footwear worn at the time of fall†related hip fracture AGE AGEING, Volume: 32  Ã‚   Issue: 3  Ã‚   Pages: 310-314. Spink, Martin J.; Fotoohabadi, Mohammad R.; Wee, Elin; (2011a) Foot and ankle strength, range of motion, posture, and deformity are associated with balance and functional ability in older adults ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION,   Volume: 92  Ã‚   Issue: 1  Ã‚   Pages: 68-75 Spink, Martin J.; Menz, Hylton B.; Fotoohabadi, Mohammad R.; Wee, Elin; Landorf, Karl B.; Hill, Keith D. Lord, Stephen R.; (2011b) Effectiveness of a multifaceted podiatry intervention to prevent falls in community dwelling older people with disabling foot pain: randomised controlled trial BRITISH MEDICAL JOURNAL, Volume: 342  Ã‚   Pages: 1-8 Tencer AF.; Koepsell TD.; Wolf ME.; Frankenfeld CL.; Buchner DM.; Kukull WA.; LaCroix AZ.; Larson EB.; Tautvydas M.; (2004) Biomechanical properties of shoes and risk of falls in older adults JOURNAL OF THE AMERICAN GERIATRICS SOCIETY; Volume: 52  Ã‚   Issue: 11  Ã‚   Pages: 1840- 1846 The role of footwear and foot characteristics in reducing falls in older people Introduction The role of footwear and foot characteristics in reducing falls in older people IntroductionFoot characteristicsFootwearConclusionsReferencesRelated Introduction The results section will look at the two main themes from this essay, namely foot characteristics and footwear and their role in falls, and will discuss the main themes in the literature within these two headings. Foot characteristics There are a number of foot characteristics associated with balance and functional ability. Ankle strength, flexibility and range of motion (inversion/eversion and dorsiflexion), hallux plantar flexion strength and plantar tactile sensitivity have been found to be significant predictors of balance and functional performance (Spink et al., 2011a; Mickle et al., 2011; Menz et al., 2005). Disabling foot pain is one of the highest risks in elderly falls and pain in the region of the toe is the most common complaint (Mickle et al. 2010). These findings are in accord with Badlissi et al. (2005) who found that hallux valgus and other toe deformities are the most common disorders. However, in contrast they also found these were often asymptomatic and had no functional limitation (Badlissi et al. 2005).   Mickle et al. (2010) found that the highest risk of falls was in elderly with higher plantar peak pressures and pressure time intervals on the MFPDI, demonstrating that those with less plantar sensitivity were at significant risk, in accord with this Mickle et al. (2010) found individuals with reduced FHFS scores had plantar fasciitis and pes cava. Disabling foot pain has been found to reduce balance, step and stride length, and walking speeds (Mickle et al. 2011). Interventions that can reduce the risk of falls in older adults are exercises to strengthen and increase flexibility in the ankle and foot. Spink et al. (2011b) showed significant reductions in falls risk of individuals that followed a regime of foot and ankle stretches and exercise. This finding is in accord with suggestions from other authors (Mickle et al. 2011; Menz et al. 2005; Spink et al. 2011a). Footwear Footwear is associated with fall risks, although there are many characteristics that make up a shoe and so these factors will be discussed in order of decreasing risk. Heel height is one of the most common factors in the risk of falls, heel heights of 4.5cm or greater have been found to increase risks (Menant et al. 2008; Menz et al. 2006; Tencer et al. 2004; Sherrington et al. 2002; Spink et al. 2011, Lord et al. 1999). Elevated heels cause significant sway and reduction of balance when compared to low heeled shoes (Menant et al. 2008). Other suboptimal shoe features include lack of adequate fixation (Sherrington et al. 2002), low heel-collared shoes (Menant et al. 2008; Sherrington et al. 2002; Lord et al. 1999) and excessive flexation (Sherrington et al. 2002; Menant et al. 2006). Bare feet, socks and slippers are quoted as higher risk of falls in a number of findings (Sherrington et al. 2002; Menz et al. 2006). Whilst shoe sole hardness is found to be a risk factor in some findin gs (Sherrington et al. 2002; Menant et al. 2008), Lord et al. (1999) found no relation between shoe hardness and risk of falls. Orthoses have been used as interventions to reduce pain in older adults with disabling foot pain, thus countering the highest risk in foot characteristics with a footwear solution (Spink et al. 2011b). Orthoses shift the weight load of the foot to areas without pain and are moulded to the individual foot. Most findings agree that the most optimal footwear to reduce the risk of falls is low heeled shoes (less than 4.5cm) and high heel-collared shoes (Menant et al. 2008; Tencer et al. 2004; Sherrington et al. 2002; Spink et al. 20011a and 2011b, Lord et al. 1999), with hard soles or reduced shoe flexibility (Menant et al. 2008; Tencer et al. 2004; Sherrington et al. 2002; Spink et al. 20011a and 2011b,) and high contact area (Tencer et al. 2004). Conclusions The role of footwear and foot characteristics and their contribution to risk of falls in an elderly population has a multiplicity of factors and an overriding weakness in the literature is being unable to take into account other factors such as musculoskeletal problems.   As risk factors can be very specific to the individual it is important to discuss the overriding risks found within the literature. Foot pain and weakness of ankle and toe are a significant risk factor of fall, as is disabling foot pain. Footwear associated with higher risk of fall includes barefoot, slippers or high heels, as well as poor or no fixation. Footwear with the least risk of fall has been found to be low heeled (less than 4.5cm) shoes with good surface area contact. Fall risk can be reduced, especially in those with disabling foot pain, by use of orthoses and shoes with good fixation, as well as targeting weakness of foot and ankle by a regime of exercise. Risk in those with symptomatic toe deformity may require medical interventions. References Badlissi, F.; Dunn, JE.; Link, CL.; (2005) Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons, JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 53  Ã‚   Issue: 6  Ã‚   Pages: 1029-1033 Lord SR.; Bashford GM; Howland A.; Munroe BJ.; (1999) Effects of shoe collar height and sole hardness on balance in older women JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 47  Ã‚   Issue: 6  Ã‚   Pages: 681-684 Menant, Jasmine C.; Steele, Julie R.; Menz, Hylton B.; (2008) Effects of footwear features on balance and stepping in older people, GERONTOLOGY,   Volume: 54  Ã‚   Issue: 1  Ã‚   Pages: 18-23 Menz, HB; Morris, ME; Lord, SR (2005) Foot and ankle characteristics associated with impaired balance and functional ability in older people, JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES,   Volume: 60  Ã‚   Issue: 12  Ã‚   Pages: 1546-1552 Menz, HB; Morris, ME; Lord, SR (2006) Footwear characteristics and risk of indoor and outdoor falls in older people, GERONTOLOGY, Volume: 52  Ã‚   Issue: 3  Ã‚   Pages: 174-180 Mickle, Karen J.; Munro, Bridget J.; Lord, Stephen R.; (2010) Foot pain, plantar pressures, and falls in older people: A prospective study, JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 58  Ã‚   Issue: 10  Ã‚   Pages: 1936-1940 Mickle, Karen J.; Munro, Bridget J.; Lord, Stephen R.; (2011) Cross-sectional analysis of foot function, functional ability, and health-related quality of life in older people with disabling foot pain ARTHRITIS CARE RESEARCH,   Volume: 63  Ã‚   Issue: 11  Ã‚   Pages: 1592-1598 Sherrington Catherine; Menz, Hylton B.; (2002) An evaluation of footwear worn at the time of fall†related hip fracture AGE AGEING, Volume: 32  Ã‚   Issue: 3  Ã‚   Pages: 310-314. Spink, Martin J.; Fotoohabadi, Mohammad R.; Wee, Elin; (2011a) Foot and ankle strength, range of motion, posture, and deformity are associated with balance and functional ability in older adults ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION,   Volume: 92  Ã‚   Issue: 1  Ã‚   Pages: 68-75 Spink, Martin J.; Menz, Hylton B.; Fotoohabadi, Mohammad R.; Wee, Elin; Landorf, Karl B.; Hill, Keith D. Lord, Stephen R.; (2011b) Effectiveness of a multifaceted podiatry intervention to prevent fall in community dwelling older people with disabling foot pain: randomised controlled trial BRITISH MEDICAL JOURNAL, Volume: 342  Ã‚   Pages: 1-8 Tencer AF.; Koepsell TD.; Wolf ME.; Frankenfeld CL.; Buchner DM.; Kukull WA.; LaCroix AZ.; Larson EB.; Tautvydas M.; (2004) Biomechanical properties of shoes and risk of fall in older adults JOURNAL OF THE AMERICAN GERIATRICS SOCIETY; Volume: 52  Ã‚   Issue: 11  Ã‚   Pages: 1840- 1846 The role of footwear and foot characteristics in reducing falls in older people Study Objective The role of footwear and foot characteristics in reducing falls in older people Study ObjectiveOutcome variablesParticipant/study selectionInclusion/exclusion criteriaRandomisationBaseline differencesInterventions usedDemographicsTime frame of studyParticipant flowStatistical analysisCompleteness of follow upReferencesRelated Study Objective The role of footwear and foot characteristics has been extensively studied in older people to understand how these factors interact to induce falls, and further to endeavour to reduce fall as this has been classified as one of the more prevalent means of injury in older adults. Studies often focus on the interactions of footwear, foot mobility and flexation, and musculoskeletal disorders of the foot. Menant et al. (2008) systematically investigated the relationship between footwear characteristics, balance and stepping in older adults. They used specially designed footwear with contrasting features which included 6 different designs, a standard shoe, identically shaped soft and hard sole, a high heel-collar shoe, an elevated heel shoe, a bevelled heel shoe, a flared sole and a tread soled shoe, which were used to assess coordinated stability and choice stepping reaction times. In contrast, Menz et al. (2006) sought to determine the relationship between footwear characteristics and th e risk of indoor and outdoor falls in older people. The study used only two shoe types that were supplied by the participants; these were a soft indoor shoe (slippers) and their normal outdoor shoes. The study explored the relationship between the footwear features and the frequency of falls in older adults by separately assessing indoor and outdoor falls. Determining the correlation between musculoskeletal foot disorders, pain and functional stability is the most common form of fall study, perhaps because these relationships have less variation than shoe characteristics. Badlissi et al. (2005) investigated the relationship between musculoskeletal disorders of the foot (for example pes cavus, pes planus, claw toe, hammertoe, mallet toe, overlapping toes, hallux valgus/bunion, bunionette, and plantar fasciitis) and foot pain and functional limitation, measured on scales of 0-100 for foot pain while functional limitations were measured as walking times on a range of 0-4, to determine how foot pain mediated the relationship. Menz et al. (2005) studied the comparative contribution of a number of foot and ankle features to performance on a range of balance and functional tests, building on previous work, to determine whether these tests could explain further variation in balance and functional performance after standard sensorimotor factors were measured. Spink et al. (2011) also investigated foot characteristics in older adults, determining the degree that foot and ankle strength, range of motion, posture, and deformity were related to performance, using tests that measured balance and functional ability. Pain studies have also been used to assess falls. Mickle et al. (2010) determined if foot pain and plantar pressure were connected with falls in older people. The investigation focussed on the association of plantar pressures with foot pain in older adults and how foot pain or dynamic plantar pressures increase the risk of falls in this population, using ambulatory data from this group of community-dwelling older people. A follow-on study by Mickle et al. (2011) sought to establish whether disabling foot pain could be associated with functional foot characteristics, functional ability, and health-related quality of life (HRQOL) in retired adults. The principal objective was to determine whether disabling foot pain was connected with foot function quality, practical ability, and HRQOL in older adults, using two definitions (A: reduced ankle dorsiflexion and hallus flexor strength. B: reduced flexor strength of the lesser toes and increased foot reaction time and postural sway). Outcome variables The outcome variables for the footwear studies used similar measurements. Menant et al. (2008) measured a series of balance and stepping tests in the eight randomly presented shoe conditions. Maximum balance range and body sway measurements, coordinated stability and Choice-Stepping Reaction Time was assessed in each footwear style. In contrast, Menz (2006) measured footwear characteristics including shoe style, ï ¬ xation (buckle, velco etc.), heel height, counter height and width, critical   tipping angle, sole rigidity and ï ¬â€šexion point, tread pattern, sole hardness and heel counter stiffness with respect to specific incidence of fall. Badlissi et al. (2005) measured foot disorders e.g pes cavus, pes planus, claw toe, hammertoe, mallet toe, overlapping toes, hallux valgus/bunion, bunionette, and plantar fasciitis against foot pain. Foot health was measured on a range of 0–100, and walk time was scored on a range of 0–4. Spink (2011) measured foot and ankle strength by dynamometry, motion range, posture, deformity, and balance tests which measured postural sway, balance range extent, lateral steadiness, co-ordinated steadiness) Functional ability tests (alternate step, sit-to-stand, timed 6-m walk) were used to assess foot and ankle strength, whereas Menz (2005) tested foot and ankle characteristics (foot posture, range of motion, strength and deformity) against sensorimotor functions, which included vision, sensation, strength and reaction time, as well as balance and functional aptitude as measured using standing and leaning balance, stepping, sit to stand and walking speeds. Mickle et al. (2010) classified participants into two categories (faller or non-faller) based on falls incidence over 12 months. Pain was calculated with the Manchester Foot Pain and Disability Index (MFPDI) that employs questions consisting of statements about the participant’s foot or foot pain. Finally, dynamic plantar pressures were measured during a walk over a pressure platform which was used to represent bare-foot dynamic foot function. Mickle et al. (2011) also employed MFPDI to establish foot pain. Foot function was characterised by foot reaction time, ankle dorsiï ¬â€šexion strength and ï ¬â€šexibility, hallux and lesser toe ï ¬â€šexor strength, and spatiotemporal gait parameters. Finally, volunteers performed postural sway tasks, those with disabling foot pain were classiï ¬ ed using original and conservative deï ¬ nitions from Short Form 36 Health Survey (SF-36).   Pain-free was subsequently compared with individuals with pain following adjustments for gen der and body mass index (BMI). Participant/study selection The participant study for these investigations was older adults of retirement age, without comparisons to younger adults. Badlissi et al. (2005) used a very large sample (n=5784) of ethnically diverse adults aged 65 and older for their study into foot disorders. For the footwear studies, Menant et al. (2008) used 29 community-dwelling volunteers recruited from a research database aged ≠¥70 years with a mean age of 79.1 (+/-3.7) years of which 15 were females, while Menant et al. (2008) had the smallest cohort with only 29 community-dwelling volunteers with a mean age of 79.1 (3.7) years. Menz et al. (2006) used 176 volunteers from a retirement village (56 men and 120 women), aged between 62–96 (mean age 80.1, SD 6.4). For the studies into foot characteristics Menz et al. (2005) used the same cohort as their previous study (n=176), while Spink et al. (2011) employed a larger randomized cross-sectional study of people (n=305) over 65 years, participants ranged between 65–93 years. The pain studies by Mickle et al.   (2010 and 2011) used the same participants of 312 community-dwelling people (154 female, 158 male) recruited from arbitrarily chosen federal electorates of New South Wales, Australia. Inclusion/exclusion criteria The exclusion criteria for all seven studies included that the participants were not bed or chair-bound; unable to ambulate household distances unaided (10m), unable to communicate in English (or Spanish (Badlissi et al. (2005)). Further exclusion criteria included neurodegenerative disorders and lower-limb amputation (Spink et al. (2011), Mickle et al. (2010 and 2011)). The ability to pass the Short Portable Mental Status Questionnaire was deemed necessary by Menz et al. (2005 and 2006) and Mickle et al. (2010 and 2011). While Mickle et al. (2010 and 2011) also stated that participants were required to arrange transport to testing venues; furthermore trials were discarded if obvious gait deviations or targeting of the pressure platform were detected. Randomisation Only studies into pain by Mickle et al. (2010 and 2011) used any form of randomisation in the choice of the study participants. Baseline differences Basline differences measured prior to studies being undertaken were performed by Menz et al. (2006) who assessed participants most-used indoor and outdoor footwear and the right shoe was characterised by a single examiner into 16 basic shoe categories. Mickle et al. (2010 and 2011) used MFPDI to establish baseline foot pain and dynamic plantar pressures. Interventions used The studies into footwear (Menant et al. (2008) and Menz et al. (2006)) employed footwear interventions, however, while Menz et al. (2006) studies shoes types already owned by the participants, Menant et al. (2008) supplied specifically designed shoes for the study. Demographics Almost all studies used volunteers from community/retirement village volunteers, apart from Mickle et al. (2010 and 2011) who recruited study volunteers from arbitrarily chosen federal electorates of New South Wales, Australia. The age range was continuous after retirement age (60+ years) without bias towards gender, race or ethnicity. Other demographic characteristics included weight, height and BMI as well as foot and other medical conditions. Time frame of study Study time-frames ranged from 1 day to 1 week, while follow-up resulted in 1 year, however, only Menz et al. (2006) and Mickle et al. (2010) required 1 year. Participant flow (No data in any of the studies related to this topic) Statistical analysis Badlissi et al. (2005) employed logistic regression to acquire adjusted-odds ratios (95% conï ¬ dence intervals) to show interaction between foot musculoskeletal disorders and pain, with potential confounders adjustment. Subsequently, stepwise multiple linear regression was used to assess variance in walk tests and foot disorders were explained by the FHFS scale scores. Menant et al. (2008) used repeated-measures ANOVA with simple contrasts for statistical analysis of the data, while Menz et al. (2006) assessed the differences in foot-wear characteristics and physiological falls risk factors between fallers and non-fallers using independent samples t-tests (for continuously scored variables) and dichotomous variables. Footwear variables with signiï ¬ cant difference between the two catagories were further assessed using logistic regression analysis with adjustment for confounders identiï ¬ ed by univariate analyses. Menz et al (2005) applied descriptive statistics with multiple and step-wise regression. To define the relationship between foot and ankle characteristics, sensorimotor measures, balance and functional test performance scores, Pearson correlation coefficients (PCC) were used. Spink et al. (2011) also employed PCC to examine relationships between foot and ankle strength and range-of-motion measures and the balance and functional test performance scores and independent sample t-tests to measure difference in balance and functional test scores with Hierarchic stepwise multiple regression analysis. Mickle et al. (2010) applied Chi-square values to establish frequency of foot pain differences between fallers and nonfallers. Independent t-tests was employed to establish signiï ¬ cant differences in peak pressure or pressure-time for the two groups and one-way analysis of covariance to ascertain signiï ¬ cance in peak plantar pressure or pressure-time integral data created by participant reports of foot pain and pain-free. Mickle et al. (2011) also used analysis of covariance tests to determine signiï ¬ cant differences in SF-36 scores, foot function, or postural sway variables in volunteers reporting foot pain or pain-free, while gender and BMI were input as covariates. Similarly, chi-square tests compared the frequency of responses between pain deï ¬ nitions. Completeness of follow up Of the seven studies investigated, only Menz et al. (2006) and Mickle et al. (2010) conducted follow up studies, which occurred one year later. The follow-up required participants to record falls over the 12 month period and comparisons were then made between ‘fallers’ and ‘non-fallers’. References Badlissi, F; Dunn, JE; Link, CL; (2005) Foot musculoskeletal disorders, pain, and foot-related functional limitation in older persons, JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 53  Ã‚   Issue: 6  Ã‚   Pages: 1029-1033 Menant, Jasmine C.; Steele, Julie R.; Menz, Hylton B.; (2008) Effects of footwear features on balance and stepping in older people, GERONTOLOGY,   Volume: 54  Ã‚   Issue: 1  Ã‚   Pages: 18-23 Menz, HB; Morris, ME; Lord, SR (2005) Foot and ankle characteristics associated with impaired balance and functional ability in older people, JOURNALS OF GERONTOLOGY SERIES A-BIOLOGICAL SCIENCES AND MEDICAL SCIENCES,   Volume: 60  Ã‚   Issue: 12  Ã‚   Pages: 1546-1552 Menz, HB; Morris, ME; Lord, SR (2006) Footwear characteristics and risk of indoor and outdoor falls in older people, GERONTOLOGY, Volume: 52  Ã‚   Issue: 3  Ã‚   Pages: 174-180 Mickle, Karen J.; Munro, Bridget J.; Lord, Stephen R.; (2010) Foot Pain, Plantar Pressures, and Falls in Older People: A Prospective Study, JOURNAL OF THE AMERICAN GERIATRICS SOCIETY, Volume: 58  Ã‚   Issue: 10  Ã‚   Pages: 1936-1940 Mickle, Karen J.; Munro, Bridget J.; Lord, Stephen R.; (2011) Cross-Sectional Analysis of Foot Function, Functional Ability, and Health-Related Quality of Life in Older People With Disabling Foot Pain ARTHRITIS CARE RESEARCH,   Volume: 63  Ã‚   Issue: 11  Ã‚   Pages: 1592-1598 Spink, Martin J.; Fotoohabadi, Mohammad R.; Wee, Elin; (2011) Foot and Ankle Strength, Range of Motion, Posture, and Deformity Are Associated With Balance and Functional Ability in Older Adults ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION,   Volume: 92  Ã‚   Issue: 1  Ã‚   Pages: 68-75